A Novel Approach to Sentence Completions: Associations between Language and Object Relations in an Inpatient Psychiatric Sample
Alex M. Ray & John T. Rucker
The study of language and psychopathology has experienced an empirical surge in recent decades. Empirical efforts have connected language to broad psychological disturbances (e.g., trauma, depression, suicidality) yet less is known about how language relates to narrow constructs governing self/interpersonal functioning (i.e., object relations). This report represents a novel approach using sentence completion test data to examine associations between linguistic expressions and distinct features of object relations. To that end, 159 consecutively admitted psychiatric inpatients were administered the Bell Object Relations and Reality Testing Inventory (BORRTI), Inventory for Personality Organization (IPO), and the Rotter Incomplete Sentences Blank (RISB) in the first week of hospital admission. Several statistically significant correlations between linguistic expressions and BORRTI and IPO scale scores emerged. Meaningful patterns of correlations are understood in the context of psychoanalytic theory and literature on language and psychopathology. Clinical implications of these research findings, alongside future directions and limitations, are discussed.
Introduction
“Whether it sees itself as an instrument of healing, of formation, or of exploration in depth, psychoanalysis
has only a single intermediary: the patient’s Word.” (Lacan, as translated by Wilden, 1968, p. 9).
The idiosyncratic nature of language use may symbolize intra- and interpersonal processes in as much as words reflect the mind’s attempt to represent and express itself (Chung & Pennebaker, 2007; Rizzuto, 2015; Tausczik & Pennebaker, 2009). Translating contents of the mind into a finite number of mutually agreed-upon, understood, and societally sanctioned words amidst unconscious factors has been found to be illuminating (Lacan, 1953/2006; Tausczik & Pennebaker, 2009). As such, careful attention to word choice and language patterns may enrich efforts to understand a patient’s mental states and structural dynamics.
The symbolic idea of words as conveyors of intrapsychic processes is not new. Indeed, there exists a theoretical and empirical basis where linguistics correlate with various aspects of psychological functioning. These linguistic markers have been identified for the study of personality typologies (Ireland & Mehl, 2014; Koutsoumpis et al., 2022; Pennebaker & King, 1999; Qiu et al., 2012; Sanford, 1942), depression (Al-Mosaiwi & Johnstone, 2018; Trifu et al., 2017; Trifu et al., 2024; Yahya et al., 2023), trauma severity (Kleim et al., 2018; Paquet et al., 2024; Qiu et al., 2024; Quillivic et al., 2025), and psychotherapeutic change (Arntz et al., 2012; Nikzad et al., 2025). Clinically, changes in patients’ linguistic patterns, such as decreased verb repetition (Halfon et al., 2017; Halfon & Weinstein, 2013), increased verbal spontaneity (Weintraub, 1981, 1989), and increased emotional and abstraction language (Mergenthaler, 1996, 1998) have been associated with treatment outcomes in psychoanalytic psychotherapy. More specifically, the evolution of patients’ emotional access and reflection has been observed through linguistic shifts (Mergenthaler, 1996, 1998; Weintraub, 1981, 1989), as well as shifts from raw affect into understandable and meaningful emotional narratives (Halfon et al., 2017; Halfon & Weinstein, 2013). More recently, Rucker and Sharp (2024) observed reflective functioning changes aligning with linguistic shifts on a sentence completion test in a mentalization-based treatment.
Alex Ray, B.S., University at Albany, State University of New York, Albany NY 12222 John Rucker, Psy.D., The Austen Riggs Center, Stockbridge, MA 01262 (USA); Menninger Department of Psychiatry and Behavior Health, Baylor College of Medicine, Houston TX 77030, johnruckerpsyd@gmail.com
Keywords: object relations, language, psychoanalysis, sentence completion
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Distinct linguistic profiles have been identified across levels of personality organization as well (Jeanneau & Armelius, 1993; Sundbom & Jeanneau, 1996). Jeanneau and Armelius (1993) found borderline personality organization-patients often used language that was impersonal, whereas neurotically organized patients used sophisticated and rich language (e.g., use of deictic words, high-level defenses); and psychotically organized patients used language that was poorly formed and lacked well-formed words or expressions. Relatedly, independent psychoanalytic scholars have proffered that identity formation and self-development are expressed in language use (Akhtar, 1995; Meissner, 2008a, 2008 b, 2008c). For example, Meissner (2008a, 2008b, 2008c) presented language acquisition, the relationship between thought and language, and the significance of pronouns as integral to self-expression, identity formation, and one's sense of self and others.
Despite these empirical advancements, less is known how language relates to narrow psychological constructs, particularly those relevant to self/interpersonal functioning (i.e., object relations). Lesser still is known how performance-based personality instruments offer a meaningful way to elicit and understand these links. The current investigation represents a novel and early attempt to empirically examine relationships between language use on a sentence completion test and features of object relations functioning. Given the scarcity of extant literature connecting these factors, our hypotheses are exploratory. First, we hypothesized that language expressions would demonstrate a meaningful pattern of associations across features of object relations functioning. Specifically, we imagined that aggression, as measured by the Inventory for Personality Organization (IPO; Clarkin et al., 2001), would correlate with anger and conflict words (Boyd et al., 2022). Relatedly, it was hypothesized that words suggesting social preoccupation (e.g., prosocial words; social behavior words; he/she/they) would be positively associated with insecure attachment, as measured by the Bell Object Relations and Reality Testing Inventory (BORRTI; Bell, 1995). Given their proposed relevance to hypermentalizing (Rucker & Sharp, 2024); Rucker & Ruffalo, 2025), it was hypothesized that all-or-none and certitude words (e.g., always, never, completely) would positively associate with the reality testing scale of the IPO as well as the reality distortion scale of the BORRTI.
Method:
Participants
All participants (N = 159) were hospitalized between October 2023 and August 2024 at a psychiatric hospital in the Southern United States. The gender of the sample was even (50.9% female), with an average age of 37.38 years (SD = 13.51). The demographic makeup was as follows: 83.0% Caucasian, 6.9% African American, 5.0 % Latin American, 4.4% Asian American, and 0.6% Pacific Islander. A smaller portion of the sample was administered Structured Clinical Interview for DSM – 5th Edition – Research Version (SCID-5-RV; First, et al., 2015) as part of standard procedures in the second week of hospitalization. The psychiatric complexity of this subsample (n = 100) is represented by M = 6.12 (SD = 5.35) personality disorder symptoms. In addition, the SCID-5-RV offered a method of categorizing whether participants met diagnostic criteria; the statistics were as follows: n = 10 bipolar disorder; n = 33 persistent depressive disorder; n = 48 major depressive disorder; n = 35 personality disorder; n = 32 comorbid personality disorder and mood disorder; n = 30 Post-Traumatic Stress Disorder; n = 47 at least one anxiety disorder; n = 42 at least one substance use disorder.
Instruments
Rotter Incomplete Sentences Blank (RISB; Rotter et al., 1992). The RISB is a performance-based personality instrument where respondent’s complete sentences to express their real feelings across 40 short, diverse sentence stems. Respondents are not given further instructions or limits on how much to write or what to write about. The sentence stems include topics about others (―Other people; A mother; Men‖),
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the self (―I failed; I need; My greatest fear is‖), and a variety of other domains (―Marriage; Sports; In school; Back home‖). The interrater reliability of the RISB has consistently proven good to excellent within contemporary psychometric standards (Joy, 2017; McCloskey, 2014; Rotter et al., 1992; Torstrick et al., 2015). The free-response element of the sentence completion method renders a collection of writing as representative of an examinee’s idiosyncratic style, psychological functioning, personality pathology, and recently, their object relations functioning (Joy, 2017; McCloskey, 2014; Piotrowski, 2018; Rucker et al., 2025; Torstrick et al., 2015).
Bell Object Relations and Reality Testing Inventory (BORRTI; Bell, 1995). The BORRTI is a 90-item true/false, self-report instrument with seven clinical scales and three validity scales. The BORRTI is anchored in ego psychology and object relations theories and was originally developed to measure the clinical impact of long-term psychoanalytic therapy for patients with severe psychopathology (Bell, 1995). The BORRTI has been well-validated, administered across a variety of treatment settings, and deemed suitable to assess one’s sense of interpersonal functioning underpinned by object relations (Hadinezhad et al., 2014; Huprich & Greenberg, 2003; Pad et al., 2020).
The Inventory for Personality Organization (IPO; Clarkin et al., 2001) is an 83-item Likert scale self-report instrument with five clinical scales and no validity scales. The five clinical scales align with Otto Kernberg’s vision of personality structures, with higher scores reflecting greater disturbance in primitive defenses, identity diffusion, reality testing, aggression, and moral values (Kernberg, 1976). The IPO has demonstrated psychometric adequacy for assessing object relations, levels of personality organization, and general psychiatric disturbance (Barreto et al., 2017; Beheydt et al., 2020; Hörz-Sagstetter et al., 2021; Unoka et al., 2022).
Linguistic Inquiry and Word Count – 22 (LIWC-22; Boyd et al., 2022). The LIWC-22 system is an online processor analyzing typed text submissions into over 120 categories of linguistic expression. Linguistic categories range from the number of pronouns and adverbs to the frequency of illness words, swear words, exclamation points, drive words, affiliation words, and more. Connections between LIWC-22 language categories and various psychological states/traits have been empirically substantiated (Boyd et al., 2022; Corbin et al., 2023; Munin et al., 2025).
Procedures
After nursing staff affirmed capacity to consent to research, each inpatient was asked to participate in the IRB-approved project. Consenting inpatients were administered the BORRTI, IPO, and RISB in the first week of hospital admission. Exclusion criteria involved being under the active effect(s) of harmful drugs and/or substances confirmed by toxicology report, being under the age of 18 or above age 80, and/or the presence of organic cognitive/physical impairment that may have hindered ability to comfortably engage with the sentence completion task (i.e., dementia, Parkinson’s Disease, Wernicke’s aphasia). Completed RISB profiles were typed into a Microsoft Word Document and submitted to the LIWC-22 processor by the primary investigator (JR).
Data Analyses
This study used Pearson correlations to investigate potential linguistic correlates of object relations use. To mitigate risk of Type I error, Pearson correlations concentrate around effect sizes with p< .01.
Results:
Several small statistically significant findings emerged between the LIWC-22 categories and
BORRTI scales. The Alienation scale reached a small negative effect size correlation with wellness words (r = -.24). The Insecure Attachment scale reached a small negative effect size correlation with prepositions (r = -.23) and money words (r = -.21). The Egocentricity scale reached a small effect size correlation with
Sentence Completions in Psychiatric Sample: 19
cause words (r = .21) and wellness words (r = -.21). The Social Incompetence scale reached a small effect size correlation with perception words (r = .22). The Reality Distortion scale reached a small effect size correlation with tone words (r = -.22), ―I‖ words (r = .21), articles (r = -.26), prepositions (r = -.21), and words with negative tones (r = .20). The Uncertainty of Perception scale reached a small effect size correlation with ―we‖ words (r = -.22), perception words (r = .21), feeling words (r = .23) and time words (r = -.27). Lastly, the Hallucinations/Delusions scale reached a small effect size correlation with ―we‖ words (r = -.21) and ―they‖ words (r = .22).
Similarly, several statistically significant findings emerged between the LIWC-22 categories and IPO scales. The Primitive Defenses scale reached a small effect size correlation with prepositions (r = -.21) and time words (r = -.24). The Identity Diffusion scale reached a small effect size correlation with ―we‖ words (r = -.21), articles (r = -.20), and prepositions (r = -.24). The Reality Testing scale reached a small effect size correlation with time words (r = -.21). The Aggression scale reached a small effect size correlation with word count (r = -.21), she/he pronouns (r = -.24), prepositions (r = -.23), anger words (r =
.23), conflict words (r = .24), and time words (r = -.22). Lastly, the Moral Values scale reached a small effect size correlation with anger words (r = .22) and time words (r = -.24).
Discussion:
This study examined the relationship between language and object relations functioning in a complex psychiatric inpatient sample. Given sparse literature connecting these topics, this discussion is brief and framed with preliminary interpretations based on correlations where p< .01. The small effects sizes suggest isolated language tools are insufficient as sole markers of psychopathology. Rather, a meaningful constellation of language tools may be more indicative of psychiatric typology.
Positive and negative associations were observed between object relations features and categories of language elicited by the RISB. This is meaningful such that a series of positive and negative correlations, representing what was and was not written, associative with object relations functioning. This lends support to the idea that intrapsychic functioning is contingent on the presence and absence of psychological pressures expressed via language. For example, the use of cause words (e.g., how, because, make, why) positively associated with Egocentricity scores on the BORRTI, whereas the use of wellness words (e.g., healthy, gym*, supported, diet) was negatively associated. This may suggest that dynamics related to narcissism may be embodied in excess attribution-based language and less language on well-being.
Our second hypothesis was confirmed such that anger (e.g., hate, mad, angry) and interpersonal conflict (e.g., fight, kill, killed, attack) words positively associated with aggression scale scores on the IPO. This lends empirical support to the notion that self/other friction is related to intrapsychic predominance of aggression, as demonstrated linguistically on the RISB (Clarkin et al., 2001; Kernberg, 1976). An unexpected pattern of meaningful associations emerged in that time words consistently reached small negative associations across four of the five personality organization structures. Whereas the nature of this pattern requires further investigation, we look towards Julius Fraser (1981) for preliminary direction. In his hierarchical theory of time, J.T. Fraser proffered that impaired reality testing disrupts temporal integration, thus making it difficult for someone to consolidate subjective experiences of time. This finding offers an early interdisciplinary link between the study of psychoanalysis and temporality.
Limitations of the study:
First, there is limited literature available from which to conceptually and methodologically situate our findings. As such, it is difficult to make definitive claims on the nature of the relationship between object relations and language use based on these results without replication studies. Further, all effect sizes were small. Prior to the generalizability of these findings, replication studies are necessary with samples representing the continuum of psychiatric severity. Researchers may also explore longitudinal designs to
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examine whether changes in language use signify changes in object relations functioning throughout psychoanalytic treatment (similar to Halfon et al., 2017; Halfon & Weinstein, 2013; Mergenthaler, 1996, 1998; Rucker & Sharp, 2024; Weintraub, 1981, 1989). Moreover, our sample lacked demographic diversity as most participants were Caucasian and identified as female. Language use varies across culture, geographical region, and education. As such, future studies might use a sample that is representative of broader diversity. Lastly, the object relations measures in this study were exclusively self-report instruments. Future studies might emphasize performance-based personality testing to measure object relations since the spontaneous demonstration of object relations is less amenable to conscious control than is suggested by face-valid item endorsements on self-report inventories (Rucker et al., 2024).
Nevertheless, the current findings are relevant to clinical practice. These results support initial speculations from Jacques Lacan by documenting an empirical relationship between language use and intrapsychic structures (i.e., object relations). In addition, this study is a step towards empirically examining psychoanalytic concepts and situates these results among advancements in separate fields of study (e.g., linguistics; temporality) to convey the interdisciplinary relevance of the concepts. Lastly, these findings demonstrated that object relations can be linked to the presence or absence of distinct linguistic expressions on an open-ended free-response task. This lends empirical support to psychoanalytic interventions that focus attention on the types and frequencies of language that unfold in the process of free association.
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